Medicare paid $38 million in erroneously documented imaging claims

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Medicare erroneously covered nearly 1.5 million outpatient ED imaging exams in 2008, resulting in $38 million of reimbursements for interpretations that were either incomplete or noncompliant with Centers for Medicare & Medicaid Services (CMS) rules, according to a Department of Health and Human Services report. In response, CMS vowed to fix most gaps, while disagreeing with one of the department’s key recommendations.
The report found that large percentages of CT scans, MRIs and x-rays performed at outpatient EDs were completed with incorrect documentation, including physician orders that were missing from medical records and exams performed under improper guidelines. Published this month by the Office of Inspector General (OIG) for the Department of Health and Human Services (HHS), the report made several recommendations to CMS that the office argued would help remedy the errors.

OIG analyzed 9.6 million Medicare claims from the 2008 National Claims History File, randomly sampling a combined total of 220 CT and MR and 220 x-ray outpatient ED imaging exams.
Based on the samples, the report concluded that 19 percent of CTs and MRIs performed in outpatient EDs were erroneous due to insufficient documentation. The estimate for x-ray exams was somewhat lower, at 14 percent.

For 12 percent of CT and MRI exams, and 9 percent of x-ray studies, physicians’ orders were discovered to be missing from medical record documentation. These amounted to a total of $27 million in Medicare claims, the report found.

The report also indicated that CMS offers inconsistent payment guidance on the timeline for reimbursable outpatient ED imaging interpretation. For 16 percent of x-ray exams and 12 percent of CTs and MRIs, for example, radiologists interpreted the films after the patients had left the ED.

CMS requires that images be interpreted at the time that the patient is being diagnosed and treated if multiple claims are filed for the patient, for example, by the ED physician and the radiologist. If only one claim is received, however, facilities are not required to confirm that the patient was still present at the time the image was interpreted.

“CMS should adopt a uniform policy for single and multiple claims for interpretation and reports of diagnostic radiology services to require that claimed services be contemporaneous or identify circumstances in which noncontemporaneous interpretations may contribute to the diagnosis and treatment of beneficiaries in hospital outpatient emergency departments,” the report stated.

According to the report, $19 million in claims for CT and MRI, and $10 million for x-ray exams, were paid to EDs that interpreted patient images after the beneficiary had left the ED. Although many of these likely did not violate Medicare rules, OIG argued that previous reports had indicated that these later interpretations may not benefit patients’ diagnoses and treatments.

CMS responded to the claims by saying that interpretations need not always be completed contemporaneous to the patient’s diagnosis and treatment in order to contribute to their diagnosis and treatment. OIG revised its recommendation to suggest a uniform policy that would make the complex billing system more navigable for providers.

CMS did concur with the report’s remaining recommendations, namely, that the agency work to educate providers on the requirement to maintain claims documentation and that CMS should take appropriate action on the erroneously reimbursed claims.